Guarding Our Antibiotic Arsenal: Simple Strategies for Reducing Community Antibiotic Exposure

Dear Editor, I read with interest the paper on the high antimicrobial resistance (AMR) of uropathogens to common antibiotics in Afghanistan.1 Concurring with the authors, I firmly advocate for the necessity to adapt stringent policies aimed at curtailing AMR. The available alternatives of treatment options for managing even uncomplicated urinary tract infections (UTIs) remain notably limited. Implementing simple measures could be just as effective, given the urgency to stop the increasing trend of AMR. Spain’s experience could serve as a model for enhancing the appropriate use of antibiotics in treating UTIs through simple interventions.2 Three years ago, we initiated an antimicrobial stewardship program in the Barcelona area, prompted by our observation that over 30% of Escherichia coli strains presented resistance to fluoroquinolones and amoxicillin-clavulanate. Despite this, many doctors continued to prescribe these antibiotics, even for uncomplicated lower UTIs. The strategy solely aimed to promote the use of narrow-spectrum first-line antibiotics for cystitis, such as nitrofurantoin and fosfomycin. Following the intervention, which comprised a 45-minute session with other doctors in primary care centers, as well as primary care out-of-hours services, infographics for doctors, nurses, and patients, and information about the resistance rates of common uropathogens and their prescribing rates, there was an increase in the use of first-line antibiotics. Most importantly, there was a significant decrease in the percentage of these antibiotics to which uropathogens showed high resistance. In this context, the low resistance of E. coli to nitrofurantoin observed in Afghanistan highlights the importance of implementing a similar policy. This would involve promoting the usage of this narrow-spectrum antibiotic while concurrently restricting the use of the Watch antibiotics, such as quinolones, amoxicillin, and cotrimoxazole. Similar to numerous other regions worldwide, the sale of over-the-counter antibiotics is widespread in Spain, despite legal restrictions. However, studies conducted in the last decade using simulated patients revealed that most cases simulating a UTI were given fosfomycin, a first-choice antibiotic in our country, given the low resistance rates of E. coli toward it (less than 10%).3 Considering the challenge of changing such a common practice as dispensing antibiotics without a medical prescription, a similar policy should be considered for implementation in other areas. Fosfomycin should not be promoted for sale in Afghan pharmacies due to the high resistance rates. Instead, nitrofurantoin could be offered as an alternative, limiting the use of other antibiotics. Changing ingrained habits like dispensing antibiotics without medical prescriptions poses a significant challenge.4 However, implementing some simple measures, such as promoting the distribution of antibiotics designated by the World Health Organization as Access antibiotics, and for short durations, could effectively mitigate the escalating rates of AMR observed globally.5 A notable concern lies in the dispensing of antibiotics for respiratory tract infections, where many uropathogens are highly resistant. Nevertheless, restricting antibiotic packaging to contain a few doses, thereby limiting therapy to a maximum of 3 days, could serve as a simple yet impactful strategy to curb the proliferation of AMR. This approach would likely have acceptance from both pharmacists and patients as pharmacists could assist patients presenting with infection symptoms,6 and patients would receive the desired medication for a short duration without compromising safety.7 Given the pressing need to address the rising threat of AMR, it is imperative to adopt straightforward interventions. These could include promoting the use of first-line narrow-spectrum antibiotics for common infections in the community and restricting the dispensing of antibiotics in community pharmacies to those classified as Access antibiotics, and only for short durations. Financial support and sponsorship None. Conflicts of interest No conflicts of interest.